Reimbursement policies | Blue Cross MN

Blue Cross and Blue Shield of Minnesota and Blue Plus (Blue Cross) has developed reimbursement policies that provide coding and reimbursement requirements for healthcare services.

Coding and reimbursement processes are subject to all terms of the Provider Service Agreement as well as changes, updates and other requirements of coding rules and guidelines. All codes are also subject to federal HIPAA rules, and in the case of medical code sets (HCPCS, CPT, ICD-10-CM), only codes valid for the date of service will be accepted. These policies are superseded by benefits and/or by state or federal requirements.

The reimbursement policies are separated by line of business (Commercial, Medicaid or Medicare). If there is not a policy for a specific line of business refer to the following sources:

Medicaid: Refer to Minnesota Health Care Program (MHCP) Provider Manual for guidance. NOTE: Blue Cross Medicaid Reimbursement Policies became effective 1/1/2024.
Medicare: Refer to Centers for Medicare & Medicaid Services (CMS) for guidance.

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Medical policy & prior authorization

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Anesthesia Services

Commercial
Commercial Anesthesia Services - 001 Anesthesia Policy Commercial Anesthesia Services - 002 Administration of Moderate (Conscious) Sedation
Medicaid
Medicaid Anesthesia Services - 001 Anesthesia Policy

Behavioral Health

Commercial
Commercial Behavioral Health - 006 Mobile Crisis and Stabilization Services Commercial Behavioral Health - 023 Facility Based Mental Health Services
Medicare
Medicare Behavioral Health - 023 Facility Based Mental Health Services

DME

Commercial
Commercial DME - 001 DME and Supplies Commercial DME - 002 Oxygen Aiding Equipment
Medicaid
Medicaid DME - 008 Durable Medical Equipment (Rent to Purchase)
Medicare
Medicare DME - 001 DME and Supplies

Evaluation and Management

Commercial
Commercial Evaluation and Management - 002 Same Day Same Service Commercial Evaluation and Management - 004 Hospital Inpatient and Observation Care Services Commercial Evaluation and Management - 005 Standby and On-Call Services Commercial Evaluation and Management - 006 Prolonged Services Commercial Evaluation and Management - 011 Preventive Medicine Services Commercial Evaluation and Management - 012 Consultation Services Commercial Evaluation and Management - 013 New Patient
Medicaid
Medicaid Evaluation and Management - 002 Same Day Same Service Medicaid Evaluation and Management - 013 New Patient Medicaid Evaluation and Management - 014 Online Digital Evaluation and Management Services
Medicare
Medicare Evaluation and Management - 002 Same Day Same Service Medicare Evaluation and Management - 004 Hospital Inpatient and Observation Care Services Medicare Evaluation and Management - 005 Standby and On-Call Services

Facility

Commercial
Commercial Facility - 002 Incremental Nursing Commercial Facility - 003 Inpatient Hospital Readmission Commercial Facility - 006 Outpatient Services Prior to an Inpatient Admission Commercial Facility - 007 Hospital Observation Care Services
Medicaid
Medicaid Facility - 002 Incremental Nursing Medicaid Facility - 003 Inpatient Hospital Readmission Medicaid Facility - 006 Outpatient Hospital Services Prior to an Inpatient Admission
Medicare
Medicare Facility - 003 Inpatient Hospital Readmission

General Coding

Commercial
Commercial General Coding - 003 Code Editing Policy Commercial General Coding - 005 Unlisted Procedure Code Commercial General Coding - 007 Telehealth and Virtual Care Services Commercial General Coding - 009 Max Units Per Day Commercial General Coding - 010 Chiropractic Services Commercial General Coding - 011 Urgent Care-After Hours Care-Extended Hours Commercial General Coding - 016 Drug Wastage Commercial General Coding - 018 Myocardial Perfusion (Cardiovascular Stress Test) Commercial General Coding - 019 Professional and Technical Components for Applicable Services Commercial General Coding - 025 Maternity Commercial General Coding - 031 Home Infusion Commercial General Coding - 038 Injection and Infusion Services Commercial General Coding - 069 Ambulance Services Commercial General Coding - 071 Bundled Services Commercial General Coding - 072 Performance Measurement Codes Commercial General Coding - 073 Clinical Trial Commercial General Coding - 074 Cellular and Gene Therapy Products Commercial General Coding - 076 Procedure Codes Not Applicable to Commercial Products Commercial General Coding - 078 Community Health Worker Commercial General Coding - 079 Hair Removal for Gender Affirming Procedures Commercial General Coding - 080 Skilled Nursing Services in the Home Commercial General Coding - 081 Inappropriate Diagnosis Code Commercial General Coding - 082 Spravato (esketamine)
Medicaid
Medicaid General Coding - 003 Code Editing Policy Medicaid General Coding - 005 Unlisted Procedure Code Policy Medicaid General Coding - 009 Maximum Units Per Day Medicaid General Coding - 071 Bundled Services Medicaid General Coding - 073 Clinical Trial Medicaid General Coding - 074 Cellular and Gene Therapy Products Medicaid General Coding - 079 Hair Removal for Gender Affirming Procedures Medicaid General Coding - 081 Inappropriate Diagnosis Code Medicaid General Coding - 082 Spravato (esketamine)
Medicare
Medicare General Coding - 003 Code Editing Policy Medicare General Coding - 005 Unlisted Procedure Code Medicare General Coding - 009 Max Units Per Day Medicare General Coding - 011 Urgent Care-After Hours Care-Extended Hours Medicare General Coding - 079 Hair Removal for Gender Affirming Procedures Medicare General Coding - 081 Inappropriate Diagnosis Code

Lab/Path Services

Commercial
Commercial Lab/Path Services - 001 Laboratory Rebundling Services Commercial Lab/Path Services - 002 Professional Component for Pathology Tests Commercial Lab/Path Services - 005 Laboratory Services - General Guides Commercial Lab/Path Services - 008 Genetic/Molecular Test Coding Commercial Lab/Path Services - 009 Urine Drug Testing
Medicaid
Medicaid Lab/Path Services - 001 Laboratory Rebundling Policy Medicaid Lab/Path Services - 008 Genetic/Molecular Test Coding

Radiology

Commercial
Commercial Radiology - 001 Radiology Services General Guide

Rehabilitative Service

Commercial
Commercial Rehabilitative Service - 004 Physical, Occupational and Speech Therapy Modalities and Evaluation
Medicaid
Medicaid Rehabilitative Services - 004 Physical, Occupational and Speech Therapy Modalities and Evaluation

Surgery/Interventional Procedure

Commercial
Commercial Surgery/Interventional Procedure - 001 Assistant at Surgery Commercial Surgery/Interventional Procedure - 002 Bilateral Procedures Commercial Surgery/Interventional Procedure - 003 Co-Surgeon and Team Surgeons Commercial Surgery/Interventional Procedure - 004 Modifier 22 Commercial Surgery/Interventional Procedure - 005 Multiple Surgical Reduction Commercial Surgery/Interventional Procedure - 006 Fracture Care Commercial Surgery/Interventional Procedure - 007 Global Surgical Package Commercial Surgery/Interventional Procedure - 008 Multiple Endoscopic Procedures Commercial Surgery/Interventional Procedure - 011 Insertion and Removal of Tympanic Ventilation Tubes Commercial Surgery/Interventional Procedure - 013 Computer Assisted Navigation in Orthopedic Surgery Commercial Surgery/Interventional Procedure - 019 Once in a Lifetime Procedures Commercial Surgery/Interventional Procedure - 021 Mohs Micrographic Commercial Surgery/Interventional Procedure - 022 Wrong Surgical and Other Invasive Procedures Commercial Surgery/Interventional Procedure - 023 Robotic-Assisted Surgery Commercial Surgery/Interventional Procedure - 024 Split Surgical Package
Medicaid
Medicaid Surgery/Interventional Procedure - 002 Bilateral Procedures Medicaid Surgery/Interventional Procedure - 003 Co-Surgeon and Team Surgeons Medicaid Surgery/Interventional Procedure - 004 Modifier 22 Medicaid Surgery/Interventional Procedure - 005 Multiple Surgical Reduction Medicaid Surgery/Interventional Procedure - 007 Global Surgical Package Medicaid Surgery/Interventional Procedure - 019 Once in a Lifetime Procedures Medicaid Surgery/Interventional Procedure - 022 Wrong Surgical and Other Invasive Procedures Medicaid Surgery/Interventional Procedure - 024 Split Surgical Package
Medicare
Medicare Surgery/Interventional Procedure - 004 Modifier 22 Medicare Surgery/Interventional Procedure - 006 Fracture Care Medicare Surgery/Interventional Procedure - 007 Global Surgical Package Medicare Surgery/Interventional Procedure - 011 Insertion and Removal of Tympanic Ventilation Tubes Medicare Surgery/Interventional Procedure - 019 Once in a Lifetime Procedures Medicare Surgery/Interventional Procedure - 022 Wrong Surgical and Other Invasive Procedures Medicare Surgery/Interventional Procedure - 023 Robotic-Assisted Surgery Medicare Surgery/Interventional Procedure - 024 Split Surgical Package